Strategies for health : An anthology

STRATEGIES

FOR HEALTH

STRATEGIES

FOR HEALTH

AN ANTHOLOGY

Linköpings universitet

Institutionen för Hälsa och Samhälle (IHS)

Department of Health and Society

S-58183 Linköping

Sweden

Published 2007

Copyright by Hanna Arneson, Kerstin Ekberg, Per Nilsen, Lennart

Nordenfelt, Elsy Söderberg

Cover design by Aaron A. Sikkink

Text editing by Diana Stark-Ekman and Per Nilsen

Printed by LiU-tryck, Linköping, Sweden, 2007

All rights reserved. Except for the quotation of short passages for

the purposes of criticism and review, no part of this publication

may be reproduced, stored in a retrieval system, or transmitted, in

any form, or by any means, electronic, mechanical, photocopying,

recording or otherwise, without the prior permission of the

pub-lisher.

ISBN: 978-91-85715-36-7

ISSN: 1652-1994

CONTENTS

PREFACE

1

UNDERSTANDING THE CONCEPT OF HEALTH

4

Lennart Nordenfelt

FROM “ACTS OF GOD” TO SAFETY

PROMOTION – A BRIEF HISTORY OF

INJURY RESEARCH

16

Per Nilsen

THE THEORY OF COMMUNITY-BASED

HEALTH AND SAFETY PROGRAMMES

– A CRITICAL EXAMINATION

28

Per Nilsen

WORKPLACE HEALTH – INFLUENCES

AND INTERVENTIONS

46

Kerstin Ekberg

EMPOWERMENT AND HEALTH

ENHANCEMENT IN WORKING LIFE

– FRAMING THE CONCEPT,

REVIEWING THE EVIDENCE

59

Hanna Arneson

SOCIETY-BASED STRATEGIES AND

MANAGEMENT ROUTINES AIMED AT

PROMOTING RETURN TO WORK

71

PREFACE

The ever-growing complexity of modern society has required that researchers expand their collaboration across scientific disciplines. Interdisciplinary research has the potential to yield insights and knowledge that cannot be achieved by re-search within an individual discipline. Although each discipline has its own con-cepts, theories, models, and methodologies that it uses to answer questions, the convergence of perspectives from multiple disciplines may stimulate new, crea-tive approaches to solving challenging research problems.

The need for interdisciplinary research was a motivating factor in the estab-lishment of Institutionen för Hälsa och Samhälle (IHS) (the Department of Health and Society) in 2002 at Linköping University, Sweden. IHS encompasses medical, philosophical, and technical faculties, and is composed of six divisions: Socialmedicin och folkhälsovetenskap (Social Medicine and Public Health Sci-ence), Rikscentrum för arbetslivsinriktad rehabilitering (National Centre for Work and Rehabilitation), Sjukgymnastik (Physiotherapy), Allmänmedicin, Cen-trum för utvärdering av medicinsk teknologi, and Tema hälsa och samhälle (Tema Health and Society).

Encouraged by the multidisciplinary research approach of IHS, scientists at the six divisions participate in three strategic research arenas. These arenas offer researchers from a variety of backgrounds a forum to expand their vocabulary to understand each other and to develop and share concepts, theories, models and methodologies, thus facilitating interdepartmental research. One of the three research arenas is Strategies for Health, which is comprised of researchers from the five divisions of the medical and philosophical faculties of IHS. Strategies for Health research recognises that health is a broad concept, en-compassing physical, mental, and spiritual dimensions. Health is fundamentally interlinked with the physical, social, cultural, and economical environments sur-rounding people. This means that health can be promoted on different levels, from individual to organisational and societal levels, and in arenas where people live, work, and play, e.g. workplaces, schools, neighbourhoods, and communi-ties.

Strategies for Health research addresses the interaction among society’s many welfare actors and the strategies and policies they implement to influence the health of individuals and populations. Intervention research is an integral element of Strategies for Health, with the aim of producing knowledge about problem analysis, design, implementation, and evaluation of interventions in order to achieve effective and sustainable solutions. Another aspect of

Strate-gies for Health research investigates socio-cultural beliefs and ideas individuals and groups have concerning their abilities and opportunities to attain health, and the strategies they use in order to improve and/or maintain their health. This anthology is comprised of six papers, introducing readers to a variety of topics relevant to the Strategies for Health arena. The papers are intended to reflect the breadth of research conducted in Strategies for Health. The aim is to contribute to a greater understanding of the concept of health and provide in-sights into some strategies for improvement of health and safety.

The opening paper by Lennart Nordenfelt, “Understanding the concept of health,” sets the scene by stating that health is not simply the absence of dis-ease, but a multidimensional concept. Nordenfelt explores a multitude of char-acterisations of health, comparing the medical (biostatistical) and holistic con-ceptions of health and disease. He argues that a holistic orientation to health is most appropriate since health in medical practice and public health contexts is considered something beyond the absence of or prevention of disease. Thus, health is best interpreted along holistic lines of reasoning.

A holistic definition of health implies that there is a broad range of strategies to promote health. The field of safety promotion has evolved from behavioural strategies predominantly aiming at changing the individual’s behaviour, to strategies that place more emphasis on modification of physical and social envi-ronments, often integrating different approaches in broad, multifaceted com-munity-oriented programmes to promote safety at the population level. The pa-per “From ‘acts of God’ to safety promotion – A brief history of injury re-search” by Per Nilsen chronicles injury research’s evolution, from its “pre-scientific” era, when injuries were considered unpreventable random events, i.e. “acts of God,” to the transformation of injury epidemiology into a science over the latter half of the twentieth century.

The community-based approach to health and safety promotion represents a shift in focus from individual accountability and “victim blaming” to explana-tions that also encompass social and environmental influences. However, de-spite wide application of community-based programmes during the last 30 years, there is a paucity of evaluations from which to obtain evidence regarding the effectiveness of these programmes. In “The theory of community-based health and safety programmes – A critical examination,” Nilsen scrutinises the theory of the community-based approach to examine whether there are short-comings in the theoretical underpinnings of this strategy that could explain the lack of convincing evidence of effectiveness.

Communities are complex “open systems,” often making it difficult to reach many subgroups. In contrast, the workplace constitutes a more clearly deline-ated environment, with ease of access to a large proportion of the adult popula-tion and established channels of communicapopula-tion. However, the workplace brings together many groups and individuals who may have different priorities

with regard to health and work, potentially yielding a conflict between the pur-suit of productivity and improvement of health. In “Workplace health – Influ-ences and interventions,” Kerstin Ekberg reviews key concepts, theories, and models to explain the relationship between health and work. She also discusses research findings concerning strategies to improve workplace health.

The workplace as an important determinant of health is further explored by Hanna Arneson in “Empowerment and health enhancement in working life – Framing the concept, reviewing the evidence.” Arneson discusses the concept of empowerment and how this has been applied within the context of working life. Empowerment is a concept that is shared across many disciplines, including community development, psychology, education, management, and studies of social movements and organisations, each contributing its own perspective to the concept. In health promotion, empowerment is a foundational concept as it constitutes a positive multi-factorial approach to health, typically being under-stood as a process through which people can gain greater control over decisions and actions affecting their health. Arneson reviews empirical research findings pertaining to empowerment in working life and its association with health, con-cluding the paper by outlining a number of key issues that require further re-search.

Despite the potential of the workplace as a setting for improving health and safety, many Western countries have experienced high and/or increasing levels of sickness absence and rising sickness insurance system costs. This develop-ment has prompted societal efforts to restore the health and functional ability of people on sick leave. However, promoting return to work in ill workers is a complex process that involves actions by and interaction between numerous actors, including employers, health and medical services, and social services. In her article, “Society-based strategies and management routines aimed at pro-moting return to work,” Elsy Söderberg looks at the strategies used by different welfare actors and pinpoints crucial difficulties associated with these efforts. Söderberg concludes her paper, and the entire anthology, by delineating impor-tant areas for further research.

UNDERSTANDING THE

CONCEPT OF HEALTH

LENNART NORDENFELT

On the value of health

Many people, in particular in modern times, have regarded health as one of the most precious values in life. Health, as well as longevity, should, they think, be protected and enhanced as much as possible. Thus, the art and science of medi-cine has received a crucial place in the modern, both Western and Eastern, soci-ety. Doctors and other health workers are important people. They are highly regarded and they are well paid in most countries. In certain circles they have replaced the priests or even the gods of old times, with the power to prolong life.

Along with the growing stature of health care providers in modern society, we can also see the rapid development of health promotion, a movement which is partly but not wholly connected to the development of medicine. Health pro-moters of various kinds play roles as advisors and supporters to many modern people. Commercial industry has followed in these steps. Huge amounts of goods that purport to be beneficial for one’s health have been marketed and successfully put up for sale.

This marketing of good health has not always been a prevalent social value. During medieval times in Western Europe one’s life on earth was not the im-portant life. This life was only a preparation for the eternal life to follow, to-gether with God. Thus, health in this life did not have the utmost value. It was much more important to successfully prepare oneself for the eternal life and thus live in accordance with the duties indicated in the holy literature, in particu-lar the Bible.

Moreover, most philosophers in Western cultures have preached other vir-tues than the healthy life. The great Plato from the fourth century BC, for in-stance, said that we should not concentrate our interest and ambition on our own health or on questions on health and disease. When people concentrate on their own health and want to consult a doctor at all times this is a sign of un-sound conditions in the state. Neither should doctors be given power over peo-ple. People should never leave the responsibility for their lives in the hands of other people.

Today, however, we find in most Western countries a great attention to health matters. In my own country, Sweden, several investigations have been made about this phenomenon. The best known studies have been performed by the Swedish professor of religious philosophy, Anders Jeffner (see Kallenberg et

al., 1997). In his studies Jeffner asked a representative sample of Swedes to

identify the attributes that they valued most in their lives. A vast majority of these people put health on top of their lists, followed by attributes such as wealth, participation in cultural activities, high social status, good family rela-tions and world peace!

Is there a good explanation of this phenomenon, where health is considered the best attribute one can have in one’s life? Indeed, I think there is such an ex-planation. Sweden is probably the most secular country in the world, even in comparison with the post-communist states, where atheism was officially preached. It is rare that Swedes expect a life after death. Thus, practically all their attention is focused on the problems of this life on earth and on having the best conditions to live this life. Health is, not unexpectedly, believed to be such a condition. Moreover, attainment of good health is now a possibility for many, where, even fifty years ago, such an outcome was well beyond the imagi-nation of many. One must remember that it is only during the last century, be-cause of the development of medicine and health promotion, that it has become possible to make radical improvements in the health status of people. Hygienic conditions in the rich countries are now such that one can usually guarantee a reasonably healthy life to their inhabitants. It has also become possible to cure or prevent some of the most deadly diseases, such as smallpox and tuberculosis. Thus, it is only recently that it has become possible to really hope for a radical improvement of the health states of people in the world.

The purpose of this paper is, however, not to discuss the sociology of to-day’s health interest. I wish instead to contribute to the understanding of the nature of health, which is the area where I have done most of my research. I shall do this mainly by comparing two kinds of philosophies of health which are dominant in the modern discussion. I shall argue in favour of one of these, viz. a holistic understanding of health. It will be evident, I think, that this under-standing is the more adequate one, especially in the light of what I have said about people’s appreciation of health. Let me however first provide a more gen-eral sketch of the philosophy of health.

Some historical theories of health

Health is a notion primarily applicable to the entirety of a human’s well-being. But there are more specific derivative notions of health. Ever since antiquity, reinforced by the Cartesian distinction between body and mind, it has been natural to separate somatic health from mental health. The interpretations of mental health have varied over time. The ancient notion of mental health was closely connected to morality, whereby the mentally healthy person was a per-son who lived a virtuous life, but this idea has lost most, though not all, of its significance today. The idea of spiritual health is also current in the health sci-ence although it is not systematically recognised. Bernhard Häring is a leading spokesman for a notion of health including a spiritual dimension, stating: “A comprehensive understanding of human health includes the greatest possible harmony of all of man’s forces and energies, the greatest possible spiritualisa-tion of man’s bodily aspect and the finest embodiment of the spiritual” (1987, page 154).

The various categories of health have connections to each other. Sometimes bodily health has been given priority in the sense that it has been viewed as a prerequisite for mental health. Galen (ca. 129-216/7) in some of his writings attempted to explain mental properties of the person in terms of specific mix-tures of the bodily parts (Galen, 1997). Consider also the ancient proverb: mens

sana in corpore sano (a healthy mind in a healthy body). In the modern discussion

about mental illness, one position, favoured in particular by medical doctors, is that all mental illness has a somatic background, i.e. that all mental illnesses – if they exist at all – are basically somatic diseases. The customary view, however, also in Western medicine, is that a person can at the same time be somatically healthy and mentally ill, or vice versa.

Health as balance

An extremely powerful idea in the history of medicine is the one that health is constituted by bodily and mental balance. The healthy person is a person in bal-ance, normally meaning that different parts and different functions of the hu-man body and mind interlock harmoniously and keep each other in check. The Hippocratic and Galenic schools (Hippocrates 460–380 BD and Galen 129-210 AD) were the first Western schools to develop this idea in a sophisticated way. They stated that a healthy body is one where the primary properties (wet, dry, cold, hot) of the body balance each other. In the medieval schools, following Galen, this idea was popularised and formulated in terms of a balance between

the four bodily humours: blood, phlegm, yellow bile, and black bile (Cp. hu-moural pathology).

The idea of balance remains strong in several non-Western medical tradi-tions. The Yahurveda tradition in India, for instance, declares that there are three humours acting in the body: breath (vata), bile (pitta), and phlegm (kapha). The proportions of the three humours vary from person to person, and their actions vary according to season, environment, the life-style of the individual, and his or her diet. In good health the humours are in equilibrium. Disease is the result of their imbalance (Singhal & Patterson, 1993).

Balance is a powerful idea also in modern Western thought, in particular within physiology. The idea is then often to be recognised under the label of

homeostasis (the Greek word for balance). Walter Cannon’s (1871-1945) classical

work on homeostasis (1930) describes in detail how the various physiological functions of the body control each other and interact in feedback loops in order to prevent major disturbances.

The idea of balance or equilibrium (the Latin word for balance) has a rather different interpretation in the writings of Ingmar Pörn. Here balance is a con-cept pertaining to the relationship between a person’s abilities and his or her goals. The healthy person, according to Pörn, is the person who can realise his or her goals and thus retain a balance between abilities and goals (see Health as ability, below).

Health as well-being

It is an important aspect of health that the body and mind are healthy, both in order and function. But we may ask for the criteria of such well-functioning. How do we know that the body and mind function well? When is the body in balance?

A traditional answer is that the person’s subjective well-being is the ultimate criterion. Simply put: when a person feels well, then he or she is healthy. This statement certainly entails problems, since a person can feel well and still have a serious disease presenting. The general idea can, however, be modified to cover this case too. The individual with a serious disease will sooner or later have negative experiences such as pain, fatigue, or anguish. Thus, the ultimate crite-rion of a person’s health is his or her present or future well-being.

It is a difficult task to characterise the well-being constituting health. If one includes too much in the concept there is a risk of identifying health with hap-piness. Indeed, a common accusation directed against the World Health Organi-sation (WHO) definition of health that it falls into this trap. Health cannot rea-sonably be identical with complete physical, mental, and social well-being, many critics say. The absurd conclusion of this conception could be that all people who are not completely successful in life would be deemed unhealthy.

Some authors (for instance, Hans-Georg Gadamer) have pointed out that phenomenological health (or health as experienced) tends to remain a forgotten subject. Health is in daily life hardly recognised at all by its subjects. People are reminded of their previous health first when it is being disrupted, when they experience the pain, nausea, or anguish of illness. Health is “felt” only under special circumstances, the major instance being after periods of illness when the person experiences relief in contrast to the previous suffering.

Thus, although well-being or absence of ill-being is an important trait in health, most modern positive characterisations of health have focused on other traits. One such trait is health as a condition for action, i.e. ability. I will return to this idea when I discuss holistic theories of health below.

Two contemporary streams of philosophy of health and

disease

As I said, two main streams of theories of health and disease have recently ap-peared in the arena. One main stream is sometimes called the medical one, or the bio-statistical one. What is typical of philosophers within this stream is that they claim that the concepts of health and disease and their allies – there is a whole network of medical concepts including illness, injury, impairment, defect, disability and handicap- are, or can be treated as, biological, or in certain cases psychological, measurable concepts. “Health” and “disease” are biological con-cepts in the same sense as “heart” and “lung” and “blood-pressure” are biologi-cal concepts. In particular, there is, according to this position, nothing evalua-tive or subjecevalua-tive about the concepts of health and disease.

The other main stream in the philosophy of health involves a completely opposing position regarding these basic matters. According to these philoso-phers, who are often called normativists or holists, health and disease are intrin-sically value-laden concepts. They cannot be totally defined in biological or psy-chological terms, if these terms are supposed to be value-neutral. To say that somebody is healthy means that this person is in a good state of body or mind, the holist claims. And to say that somebody has attracted a disease is to say that this person has attracted something which is bad for him or her.

What I have done so far is just to give a superficial and rough demarcation of two lines of thought within this subject. It is very complicated to spell out and disentangle the different versions of these lines of thought. At least on the holistic side there are a number of versions. What I shall do here is rather to simplify matters and concentrate on a specific version of each line of thought and analyse them in more detail.

Boorse’s biostatistical theory of health and disease

The choice of theory on the biological side is very easy. The articles by the American Christopher Boorse have dominated the arena. They have also been the target of most of the normative counterclaims. In presenting Boorse’s the-ory I shall use the most recent formulations made by Boorse himself in his long defensive article, published in 1997, titled A Rebuttal on Health.

The aim of Boorse’s biostatistical theory of disease (BST) is to analyse the normal-pathological distinction. In order to capture the modern Western con-cept of disease Boorse proposes an explication of the ancient idea that the nor-mal is the same as the natural in saying that health is conformity to species de-sign. In modern terms, Boorse says “species design is the internal functional organization typical of species members, viz.: the interlocking hierarchy of func-tional processes, at every level from organelle to cell to tissue to organ to gross behaviour, by which organisms of a given species maintain and renew their life” (1997, page 7). All conditions which are called pathological by ordinary medi-cine are disrupted part-functions at some level of this hierarchy, he says.

With this general description as a background Boorse presents the following definitions:

“1. The reference class is a natural class of organisms of uniform functional de-sign; specifically, an age group of a sex of a species, such as the human be-ing.

2. A normal function of a part or process within members of the reference class is a statistically typical contribution by it to their individual survival and reproduction.

3. A disease is a type of internal state which is either an impairment of normal functional ability, i.e. a reduction of one or more functional abilities below typical efficiency, or a limitation on functional ability caused by environ-mental agents.

4. Health is the absence of disease” (1997, page 7-8). 1 An action-theoretic theory of health and disease

Some of the theories on the holistic side also focus on goals, but they do so in a very different way. They do not refer to biological goals but to goals in the or-_______________________

Footnote 1: In my most recent formulations, for instance in Action, Ability and

Health, page 93, I use the locution “accepted circumstances” instead of

dinary human sense, viz. goals of intentional actions. When we intend to do something we automatically intend to achieve a goal. Such a goal is not a goal of just a particular organ. It is a goal of the whole human being. Thus, these theo-ries are often called holistic theotheo-ries.

It is significant that the holistic theories (HTH) consider the concept of health to be the primary one and disease as a secondary concept. Health has its basis on the level of the whole person. It is the person, not the individual or-gans, who is healthy. Let me put this general idea of health in the old way once expressed by Galen, the famous Roman physician and philosopher from 200 AD: Health is a state in which we neither suffer from evil nor are prevented from the functions

of daily life. Let me then introduce my own specification of this general idea: A

person A is completely healthy, if and only if, A is in a mental and bodily state, given standard circumstances, which is such that A has the second-order ability to realise all his or her vital goals, i.e. the states of affairs which are necessary and together sufficient for A’s minimal happiness in the long run.

According to the HTH a person is to some extent ill when he or she does not fully possess such ability. A state of illness can have various causes within the person’s body or mind. Such causes of ill health as are common or typical are what we designate as diseases. Thus, diseases, according to the HTH, are such bodily and mental states of affairs that contribute to their bearer’s ill health.

Two kinds of phenomena have a central place in traditional holistic accounts of health and illness. First, the presence of a certain kind of feeling, of ease or well-being in the case of health, and of pain or suffering in the case of illness; second the phenomenon of ability or disability, the former an indication of health, the latter of illness. These two kinds of phenomena are in many ways interconnected. There is first an empirical, causal connection. A feeling of ease or well-being contributes causally to the ability of its bearer. A feeling of pain or suffering may directly cause some degree of disability. Conversely, a subject’s perception of her ability or disability greatly influences her emotional state. In my own analysis I make an assumption of a strong connection between suffering and disability, where suffering is taken to be a highly general concept covering both physical pain and mental distress. A person cannot experience great suffering without evincing some degree of disability. But the converse re-lation does not always hold: a person may have a disability, and even be disabled in several respects, without suffering. There are, for instance, paradigm cases of ill health where suffering is absent. One obvious case is that of coma, when a person does not feel anything at all. Another concerns certain mental disabilities and illnesses. In general, when a patient cannot reflect properly on her own situation, then her disabilities need not have suffering as a consequence. In short, therefore, wherever there is great suffering there is disability, but the con-verse is not true.

These observations imply that the concept of disability must have a more central place in the defining characterization of ill health than the corresponding concept of suffering. If one of these notions is essential to the concept of ill health it must be disability. This conclusion does not deny the extreme impor-tance of pain and suffering – as experiences and not just as causes of disability – in most instances of ill health.

Towards an assessment of the BST and the HTH Consider now the two theories which we are going to compare.

I. The BSTapproach. A is completely healthy, if and only if, all organs of A

function normally, i.e. make their species-typical contribution to the survival of the individual and the species, given a statistically normal environment. A dis-ease is a subnormal functioning of a bodily or mental part of the human being. II. The HTH approach. A is completely healthy, if and only if, A is in a bodily

and mental state which is such that A is able to achieve all his or her vital goals, given standard circumstances. A disease is a bodily or mental process which tends to reduce the health (as holistically understood) of the human being.

What are the criteria for assessing concepts of health, illness and disease? By what standards can we say that either of the two theories is superior to the other?

There are several possible criteria for assessing the concepts. I will here only choose two, but I think important, criteria: usefulness in medical practice and usefulness in public health contexts. Let me then first consider the medical

en-counter, the encounter between a potential patient and a medical carer (a doctor,

a nurse or a paramedic). In order to do this I shall tell a short story.

1. A person approaches health care with a problem. John approaches his family

doctor with a problem. He says that he has been ill for some time. He has had considerable pain in his stomach and this has prevented him from going to work for a week. He says that he must have some disease. He cannot explain his ill health otherwise. Here we see that John asserts that he is ill. He has not made any inspection of his body in order to establish this fact. He has noticed his pain (a pain which has no immediate external cause) and he observes that he is pre-vented from going to work. He assumes that there is a disease which is respon-sible for this problem.

2. The doctor diagnoses the problem and treats the patient. The doctor makes an

ex-amination of John. He tries to assess the nature of the problem and when he is convinced about its nature, he seeks the causes of it. Given his medical training he will in the first instance try to find the causes of the problem in the organic functioning of John’s body. In short, he seeks some disease. It is however im-portant here to see that he is not seeking a disease for its own sake. He is not seeking any old malady. He wants to find the cause of the patient’s problem, primarily

in terms of the disease language to be found in medical classifications and text-books. Having found a disease that he believes to be the cause of the problem he starts treating it lege artis, i.e. according to the recommendations of the con-temporary art of medicine.

3. The patient is healthy again when he or she no longer has the problem. The medical

encounter is considered successful, in particular by John, when he no longer feels the pain in the stomach and can go to work as usual.

This simple exposition of the typical successful medical encounter indicates to me that the health concept used is a variant of the HTH. The establishment of the fact that John is ill, in the first place, does not presuppose any internal inspection on the organ level. John can himself (at least equally as well as the doctor) determine that he is in a state of ill health. Ill health for John is when he is in pain and unable to do something urgent for him, viz. go to work, given that the circumstances are standard, i.e. not in themselves directly preventative. Second, it is clear that health as assumed by the patient, as well as by the health care personnel, is a state of affairs over and above the absence of disease. Health has not been restored just because a disease has been cured. Normally, the pa-tient is not completely healthy, i.e. he cannot go to work, until after a time of recovery and rehabilitation. This also speaks in favour of the HTH interpreta-tion of health.

Consider now an example taken from the field of general health promotion. There are nowadays many health-promotive campaigns in all countries which concern things such as healthy eating, physical exercise, moderate consumption of alcohol and abstention from smoking. What are the underlying reasons for these health promotion campaigns, according to the two models of BST and HTH? Are both models equally successful in providing a philosophical founda-tion for this work? Let us call this quesfounda-tion the case of general health-promotive

pro-grammes.

The answer to the question about which model motivates health promotion efforts best is certainly dependent on how the situation is interpreted. A pro-tagonist of the HTH would say that this case clearly speaks in favour of the HTH. General health promotion, they would say, has not primarily to do with the prevention of disease. The primary aim is that the subject should feel hale and hearty and in general be able to achieve the things he or she is aiming for. This goal certainly presupposes the prevention of all serious diseases. It need not, however, presuppose the prevention of all pathology. Being fit and able is clearly compatible with the presence of many trivial diseases.

A defender of the BST, on the other hand, would perhaps argue along the following lines: It may be true that a general health-promotive programme need not have identified a particular disease or range of diseases as its target. From this does not follow, however, that the goal is not to prevent the incidence of serious disease. In the case where abstention from smoke or alcohol is at issue it

is clear that there are some salient diseases that the promoters have in mind. Cardiac and respiratory diseases, as well as a number of cancers, are in focus in the case of smoking. Neurological diseases, liver cirrhosis, and indeed physical accidents are in focus in the case of grave alcohol abuse. If they aim for some-thing more they are, one could argue, also some other kind of programme, for instance, a “fitness programme,” which should be held logically separate from the health promotion proper.

My answer to this, in favour of the HTH, is the following. It seems very ar-tificial and implausible to say that broad health-promotive programmes, with their very general recommendations concerning people’s lifestyle, are aiming at disease prevention and nothing more. To say that the remaining part of the pro-gramme is logically unrelated to health seems to be a purely theoretical stipula-tion against the ordinary use of language. To adopt the BST as being the most adequate theory to propel general health promotion would, I think, be to legis-late against ordinary language.

This then completes my brief argument in favour of the holistic theory of health.

On the relation between health and happiness

An important question remains to be answered. What is the relation between health and happiness given a holistic approach? If health has to do with the re-alisation of a person’s vital goals then it seems as if health comes quite close to happiness. But is this a sign that something is wrong with the holistic theory? Before answering this question we may notice that there exists a celebrated definition of health which comes even closer to identifying health with happi-ness. Let us refer again to the definition from WHO, which says that “health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” This definition characterises an ideal state, a state which is almost never reached by any human in the world. It is a utopian definition, which could hardly be used in the context of ordinary health care. It is also highly debatable whether it is at all adequate to capture the notion of health.

My own attitude to conceptual analysis is that notions which are held apart in ordinary language should also be held apart in a philosophical reconstruction of these concepts. According to ordinary understanding health and happiness are different. A healthy man can be unhappy, for instance because of financial difficulties or because of the loss of a loved one. An unhealthy person can be very happy. One can easily imagine even a dying person who is happy in the presence of her family and in the firm conviction that she is soon going to meet her God.

So is there then a conceptual relation at all between health and happiness in my view? Yes, there is and I think that this is also in accordance with the ordi-nary understanding. It is evident that health is normally conducive to happiness. If one has the capabilities involved in health, if one can do most of the things one wants to do, then it is quite likely that one is happy with life. Conversely, if one is disabled and is in pain, then most probably one is quite unhappy. This all follows from standard definitions of happiness where happiness is understood as an emotion due to one’s recognition that the conditions in life are as one would like them to be.

I do not only think that this holds as a matter of empirical fact. I also think that one should define health as a state of affairs which tends to lead to a certain degree of happiness. This is also what I do in my more technical characterisa-tion to be found, for instance in the book Health, Science and Ordinary Language.

Conclusion

In this paper I have set out to discuss a set of topics related to our understand-ing of health. I have noticed the great interest dedicated to health by a majority of Westerners of today and tried to formulate an explanation of this fact in terms of the strong secular movement in the modern world, and also in terms of the medical development. After an introduction of historical approaches, I described two major competing conceptions of health and related concepts. I have tried to compare a biostatistical theory of health and disease with a holistic one. I have noticed the essential differences and similarities between the two approaches. I have also initiated an assessment of the two conceptions, mainly from the point of view of medical practice and public health.

My conclusions from this preliminary assessment are the following:

a) The health concept used in clinical practice is related to vital goals and not just to survival. Moreover, health is something over and above the absence of disease.

b) The health concept used in the context of general health promotion is, I argue, much more naturally interpreted along holistic lines than along biostatis-tical lines.

Finally, I have commented on the relation between the notions of health and happiness. I have argued for the case that these notions are separate, but still related to each other. Health is in my view a typical, but indeed not neces-sary, contributor to happiness.

References

Boorse C (1997). A Rebuttal on Health. In: What is Disease? Biomedical Ethics

Re-views. Humber J, Almeder R, editors. New Jersey: Humana Press. Pp: 1-134.

Constitution of the World Health Organization (1946). In: Official Records of the

World Health Organization, Vol. 2:100.

Gadamer H-G (1993). Über die Verborgenheit der Gesundheit. Frankfurt am Main: Suhrkamp Verlag.

Galen (1997). Selected Works, translated with an introduction and notes by PN Singer. Oxford: Oxford University Press.

Kallenberg K, Bråkenhielm CR, Larsson G (1997). Tro och värderingar i 90-talets

Sverige. Örebro: Libris. [In Swedish]

Nordenfelt L (2000). Action, Ability and Health: Essays in the Philosophy of Action

and Welfare. Dordrecht: Kluwer Academic Publishers.

Nordenfelt L (2001). Health, Science and Ordinary Language. Amsterdam: Rodopi. Plato (1998). The Republic. In: Complete Works. Cooper JM, editor. Indianapolis:

Hackett Publishing Company.

Pörn I (1993). Health and Adaptedness. Theoretical Medicine, Vol. 14: 295-304. Singhal GD, Patterson TJS (1993). Synopsis of Ayurveda, based on a translation of

FROM “ACTS OF GOD” TO

SAFETY PROMOTION – A

BRIEF HISTORY OF INJURY

RESEARCH

PER NILSEN

Introduction

Injuries constitute a major public health problem. Throughout the world, ap-proximately 5 million people die annually as a result of injuries (WHO, 2002). This figure is expected to increase to more than 8 million people in 2020. As deaths from infectious diseases have declined, injuries have become the third leading cause of overall mortality and the leading cause of death among the 1 to 40 year old age group in industrialised countries (WHO, 2004). However, fatal injuries are only part of the picture. Millions of people are injured each year and survive. For every death due to injury in Sweden, there are approximately 30 hospitalisations and 200 out-patient injuries treated at emergency departments (SRV, 2004).

For many who experience an injury, it causes temporary pain and inconven-ience, but for some, an injury leads to disability, chronic pain, and a profound change in lifestyle. An injury affects more than just the individual injured; it af-fects everyone who is involved in the injured person’s life. With a fatal injury, family, friends, co-workers, employers, and other members of the injured per-son’s community feel the loss. In addition to experiencing grief, they may ex-perience a loss of income and/or the loss of a primary caregiver. With a nonfa-tal injury, family members are often called upon to care for the injured person, which can result in stress, time away from work, and lost income. Friends of the injured may be called upon to help out and the injured person’s employer may struggle with temporary or permanent replacements. Others in the community such as neighbours, volunteer groups, and religious organisations, may also feel the effects of the injury.

Although the greatest cost of injury is caused through human suffering and loss, the financial costs associated with injuries are far from trivial. Almost 50% of the world’s injury-related mortality occurs in young people, aged between 15 and 44 years, who comprise the most economically productive members of the

global population (WHO, 2002). Limited societal resources are required to treat and rehabilitate injured workers. Societal costs are incurred when injuries take place, as absenteeism leads to a loss of productivity and the previously discussed intangible costs affect injured workers and their social networks.

This text provides a brief account of the evolution of injury research. While injuries have been a leading cause of death and disability throughout the history of mankind, they were not scientifically studied until well into the twentieth cen-tury. The most influential factor delaying scientific attention to injuries was probably the notion that they are unpreventable random events. William Had-don, Jr. observed in 1968 that the injury field “still includes the only substantial, remaining categories of human morbidity and mortality still viewed by most laymen and professionals alike in essentially pre-scientific terms” (Haddon, 1968, page 1431). However, the pioneering work of Haddon and other injury researchers transformed how injury was conceptualised. With evolving under-standing of injury in scientific terms, opportunities for prevention of injury be-came possible.

Chance or fault

For centuries, injuries were regarded either as random, unpredictable, and un-avoidable “acts of God” or as untoward consequences of human malevolence or carelessness (Reason, 2000). However, with the advent of industrialisation in the nineteenth century, environmental risk factors for injury became more dis-cernible and the challenges of “accident prevention” began to receive attention (Bonnie & Gayer, 2002). The industrial revolution led to urbanisation and the development of factories. These environments produced new hazards, signifi-cantly increasing the injury risk, to the extent that injuries became an accepted part of ordinary life (Berger & Mohan, 1996).

Political movements for worker protection developed in Europe in the mid-nineteenth century and later in America, yet injuries were considered an un-avoidable consequence of economic development, a perspective which is an ongoing issue in the developing countries of the world even today. Although interest in work and road environment safety grew over the course of the nine-teenth century, systematic scientific inquiry was rare as injury was predomi-nantly considered in terms of chance and fault (Stevenson et al., 2004).

For much of the first half of the twentieth century, injury research focused mainly seeking to identify human errors that led to injury. The research was based on the premise that people who were injured were careless, stupid, or in-different (AAP, 1997). In keeping with the level of knowledge of the day, inter-ventions focused exclusively on the implementation of educational measures in order to eradicate careless behaviour (Waller, 1989).

This emphasis on individual responsibility has been attributed to the highly individualistic, independent frontier America. The focus on educating people how to avoid accidents is understandable given the historical settings of sparsely populated areas where formal societal structure was still lacking and where peo-ple made their own tools and built their own houses (Christoffel & Gallagher, 1999). Another reason for the person-oriented approach may lie in the emer-gence of the new field of psychiatry, which emphasised emotional antecedents to life events (Waller, 1994). The “theory of accident proneness,” devised in the 1920s, postulated that people were subconsciously “accident prone.” According to this theory, some individuals possess certain stable properties that make them particularly liable to accidents. A consequence of the theory was the notion that accidents should be prevented by selecting individuals, e.g. by using various testing procedures, and allocating them tasks that are appropriate. However, it proved difficult to distinguish accident-proneness properties of the individual from variations in exposure to hazards in the environment (Harms-Ringdahl, 1993).

Biomechanics and epidemiology

The first changes to the prevailing attitude of attributing injuries to chance or individual fault emerged in the 1940s with the work of Hugh De Haven, a pilot and physiology researcher. In 1942, De Haven published a landmark paper in

War Medicine entitled “Mechanical Analysis of Survival in Falls from Heights of

Fifty to One Hundred and Fifty Feet.” De Haven had ruptured his liver, pan-creas, and gall bladder in an airplane crash in 1919. During his convalescence, he began to question the inevitability of injury as a result of aviation crashes. However, he did not ask why his plane had crashed, but rather asked why he had survived while another occupant had been killed (Winston, 2000). By inves-tigating how people successfully survived falls of 50 to 150 feet, in some cases with only minor injury, through proper dispersion of kinetic energy in amounts as great as 200 times the force of gravity, De Haven demonstrated that damage in an injury event was not inevitable. He concluded, “It is reasonable to assume that structural provisions to reduce impact and distribute pressure can enhance survival and modify injury within wide limits in aircraft and automobile acci-dents” (De Haven, 1942, as reproduced in Winston, 2000, page 68).

De Haven’s observations signalled the birth of the field of biomechanics (Waller, 1989). Further work in this area was undertaken by Lieut. Col. John P. Stapp. He conducted several experiments for the US Air Force on biomechani-cal influences at the time of crash events, as reported in “Human Tolerance to Deceleration,” published in the American Journal of Surgery in 1957 (Stapp, 1957). He is known for strapping himself into a rocket sled with a shoulder harness to

test the ability of the harness to withstand energy transfer forces on rapid decel-eration.

Changes in epidemiologic research in the 1940s and 1950s further developed injury research. In the beginning of the twentieth century, work in epidemiology focused on reducing the burden of infectious disease. However, the develop-ment of vaccines and antibiotics and their success in reducing infectious dis-eases led to a shift in emphasis in epidemiology to the investigation of chronic diseases. As researchers began to search for new areas in which to conduct re-search, a few settled onto injuries (Haddon et al., 1964). Harvard epidemiologist John E. Gordon saw that the study of injuries had many similarities to the study of infectious diseases. Introducing the concept of injury epidemiology, Gordon suggested in his 1949 paper “The Epidemiology of Accidents” in the American

Journal of Public Health that injuries behaved like classic infectious diseases. His

studies of injury distribution patterns, according to such factors as age, place, and time, demonstrated the non-randomness of injury events (Runyan, 2003). Gordon further argued that each injury was the product not of one cause, but of forces from the three sources of the classic triad of epidemiology, i.e. the host (the individual at risk), the agent (the available energy), and the environ-ment (the physical, biologic, and socioeconomic context, in Gordon’s work) in which host and agent find themselves (Gordon, 1949).

In 1961, James J. Gibson, an experimental psychologist, elaborated on Gordon’s “injury as a disease” concept by observing in “The Contribution of Experimental Psychology to the Formulation of the Problem of Safety” (in-cluded in Behavioural Approaches to Accident Research) that there are only five agents in all injury events, namely the five forms of physical energy: thermal, radiant, chemical, electrical, and kinetic (or mechanical) energy (Gibson, 1964). Gibson suggested that injury is due to transfer of energy to the host in amounts that ex-ceed the threshold for tissue damage (Robertson, 1998). This conceptualisation of energy as the causal agent provided the basis to view the injury event as sepa-rate from the damage to the body (Rivara, 2001).

Haddon’s contributions

The host-agent-environment model proved to be a powerful concept to aid the development of interventions that address different aspects of the injury prob-lem. However, Gordon, Gibson, and others failed to identify the “agents” in the model; they were confused because potential agents of injury, i.e. injurious objects such as bicycles, cars, stairs, stoves, and knives, seemed unlimited (Bon-nie & Guyer, 2002). This dilemma was resolved in 1963 by William Haddon, a public health physician and engineer (who trained under Gordon). Haddon rec-ognised that what had previously been thought to be agents were in fact

vehi-cles and vectors for the five energy forms. Hence, injurious objects like bicyvehi-cles, cars, stairs, stoves, and knives simply represent a multitude of vehicles and vec-tors for carrying the energy. Haddon also noted that in a few types of injury events, such as drowning and hypothermia, the damage is caused, not by trans-fer of energy to the person, but rather by intertrans-ference with normal energy ex-change patterns, such as breathing or maintaining body temperature (Haddon, 1963). These groundbreaking findings, which Haddon labelled “the new theory of accident causation,” were published in the paper “A Note Concerning Acci-dent Theory and Research with Special Reference to Motor Vehicle AcciAcci-dents” (included in Annals New York Academy of Sciences).

Haddon’s 1964 book, Accident Research: Methods and Approaches, co-authored with Edward Suchman and David Klein, was a milestone in developing accident research (as it was known then) as a science. The book compiled together im-portant research contributions from more than 50 researchers, including De Haven, Stapp, Gordon, and Gibson. Haddon and colleagues urged that injury research advance from what they termed “pre-scientific” thinking to applying scientific principles to understanding injury (Haddon et al., 1964). The book es-tablished the basic principles of the injury field and was a catalyst for the subse-quent development of injury research (Bonnie & Guyer, 2002).

In 1968, Haddon further contributed to the understanding of injury occur-rence by demonstrating in “The Changing Approach to the Epidemiology, Pre-vention, and Amelioration of Trauma: The Transition to Approaches Etiologi-cally Rather than Descriptively Based” published in the American Journal of Public

Health, that all injury involves three consecutive phases, which he termed the

“crash sequence.” This sequence begins with a phase that has variously been called the pre-injury or pre-event phase, in which loss of control in management of the energy source takes place. This phase has traditionally been referred to as an “accident.” In the second phase, known as injury or event phase, the now errant energy is transferred to people and property. The nature and extent of this transfer determines whether injury occurs and its initial severity. In the third phase, the post-injury or post-event phase, efforts are undertaken to limit any ongoing damage processes, regain physiological homeostasis, and repair the damage (Haddon, 1968).

In his seminal 1970 paper “On the Escape of Tigers: an Ecological Note” in the American Journal of Public Health, Haddon expanded his three-phase injury sequence model by combining it with the three epidemiologic factors (host, vec-tor/vehicle, and environment) to form a nine-cell matrix, the so-called Haddon Matrix. The paper also described 10 prevention strategies, also arranged tempo-rally, which represent the various ways in which energy transfer can be con-trolled, modified, or interrupted (Haddon, 1970). Haddon argued that under-standing how the temporal events of an injury and its epidemiologic compo-nents work together can help researchers and practitioners plan prevention

strategies (Christoffel & Gallagher, 1999). Haddon later refined his matrix, cre-ating a 12-cell matrix by listing the columns as human (or host), vehicles and equipment, physical environment, and socioeconomic environment. Still later, he revised the model to consider topics other than traffic crashes (Runyan, 2003). The Haddon Matrix has proven a highly useful tool for analysing injury events and identifying factors important to their prevention. Haddon’s contri-butions demonstrated the practical value of using theory and conceptual models to guide prevention (Robertson, 1998).

The era of legislation

The work of Haddon was monumental; he transformed how injury was concep-tualised, shaping modern injury science as a distinct field. Haddon’s early 1960s work, which focused on road traffic safety, markedly influenced a young Ralph Nader. He explored engineering design of automobiles and wrote Unsafe at Any

Speed: The Designed-In Dangers of the American Automobile. The book, published in

1965, asked why thousands of Americans were being killed or injured in car ac-cidents when the technology already existed to make cars safer (Academy of Achievement, 2006). The chief target of the book was General Motors’ Corvair, a car whose faulty rear suspension system made it possible to skid violently and roll over. More generally, Nader’s book documented how the auto industry in Detroit habitually subordinated safety to style and marketing concerns. The main cause of car injuries, Nader demonstrated, was not the “nut behind the wheel” so often blamed by the auto industry, but the inherent engineering and design deficiencies of the motor vehicle (Nader, 1991).

Worried about litigation challenging the Corvair’s safety, General Motors hired private detectives to tail Nader in an attempt to dig up information that might discredit him; they even had women accost him in an apparent seduction scheme. Upon learning of the company’s dirty tricks, Nader successfully sued the company for invasion of privacy and forced it to publicly apologise. This remarkable incident catapulted auto safety into the public spotlight. Nader be-came a catalyst for consumer empowerment for improved ergonomically de-signed safety equipment in motor vehicles (Pearn et al., 2004).

Spurred by Nader’s book, the US Congress enacted the Highway Safety Act, which incorporated a system of motor vehicle safety standards organised ac-cording to Haddon’s pre-injury, injury, and post-injury phases (Christoffel & Gallagher, 1999). In 1966, the Congress empowered a new federal agency, the National Highway Safety Bureau (now the National Highway Traffic Safety Administration) to set motor vehicle safety standards and to award grants for research and programs promoting highway safety. Haddon became the first di-rector of the new agency. Similar regulations were enacted with the

Occupa-tional Safety and Health Act in 1970 and the Consumer Product Safety Act in 1972 (Rivara, 2001). Internationally, safety legislation also increased from the 1970s. Improved ergonomic design for safety became enshrined in a number of government and private organisations established to define standards for build-ing and quality control in various professions and industries (Pearn et al., 2004).

Toward safety promotion

The dominant injury prevention strategy until about the 1970s was education, with interventions and programmes aimed at teaching people how to avoid ac-cidents on the assumption that people will act in their own interest once in-formed of risks and benefits (Fincham, 1992). Individual error, negligence, mis-use or abmis-use of equipment, and carelessness were viewed as the most common causes of injuries (Barry, 1975). Consequently, most research was directed to-ward uncovering human factors in injury aetiology (Westaby, 1974). However, the contributions of Haddon, Nader and many others helped to shift injury pre-vention away from the long-standing person-oriented “victim blaming” ap-proach. Haddon and colleagues focused attention to human-environmental in-teractions and to application of environmental modifications when behavioural change either was unlikely or not cost-effective (Hanson et al., 2004). During the 1970s, the pendulum swung in their direction and the injury field increasingly became characterised by an emphasis on environmental strategies (Bonnie, 1999). This shift in perspective generated considerable tension between those who supported environmental responses and those who still favoured behav-ioural perspectives to injury prevention (Christoffel & Gallagher, 1999).

With the growing recognition that neither environmental nor behavioural solutions by themselves held the complete answer to the prevention of injuries, the 1980s saw an increasing number of injury prevention programmes that com-bined behavioural and environmental prevention strategies, thus balancing a personal and collective responsibility for the safety problem (Waller, 1994). Be-havioural perspectives were increasingly viewed as complementary rather than antagonistic to environmental perspectives. This shift reflected an increased awareness that environmental change cannot be accomplished without changing attitudes and behaviours in a target audience (Waller, 1989). There was also a growing recognition that individuals cannot be considered separately from their social context and that multiple interventions extending beyond the individual level are most effective (Hanson et al., 2004).

Today, injury prevention has become an increasingly collaborative undertak-ing. Injury scientists and prevention practitioners need partners in order to mount successful interventions and programs. Community-based multi-strategy programmes have emerged as an important approach to injury prevention,

mak-ing it possible to deal with injury problems in less clearly delineated areas than the road traffic and work environment, including home and leisure safety (Moller, 1992). The community-based approach underpins a growing number of national and international injury prevention movements, including the World Health Organisation (WHO) Safe Community (WHO Collaborating Centre on Community Safety, 2006), the Worldwide National Safe Kids Campaign (Worldwide Safe Kids Campaign, 2005), the Canadian Safe Communities Foun-dation (SCF, 2006), Australian Safe Communities FounFoun-dation (ASCF, 2006), and the Safe Communities Foundation of New Zealand (SCFNZ, 2005). These programmes are often referred to as safety promotion programmes as they tar-get structural determinants of safety and not merely individual risk factors (Svanström, 2000). Safety promotion programmes typically involve community members and local organisations in the planning and implementation of inter-ventions (Jeffs et al., 1993).

Broadening the field

The publication in 1985 of the report Injury In America: A Continuing Public Health

Problem by the Committee on Trauma Research (established by the National

Re-search Council (NRC) and the Institute of Medicine (IOM) of the National Academy of Sciences (NAS)) is widely considered the most important milestone in injury research since the pioneering work of Haddon in the 1960s and 1970s. The report helped to redefine the direction of injury research, setting forth the rationale for conceptualising “injury prevention and control” as a distinct field of interdisciplinary research by drawing together what had been separate strands of scientific study within the framework of public health (Bonnie & Guyer, 2002).

Injury In America: A Continuing Public Health Problem explicitly recognised that

the public health paradigm (surveillance, risk factor identification, evaluation, and intervention implementation) could be usefully applied to the prevention of intentional injuries as well as unintentional injuries (Bonnie, 1999). Knowledge about intentional injuries was identified as a major gap in current research. The report observed that these types of injuries typically have been regarded as a crime problem, rather than as a health problem. The report also expressed con-cern over the paucity of application of promising research results in the field of rehabilitation (Waller, 1989).

Injury In America: A Continuing Public Health Problem resulted in a remarkable

acceleration of injury research not only in the US, but around the world. The report recommended a major investment in injury research, commensurate with the magnitude of the problem, and proposed the creation of a centre for injury research within the US Centers for Disease Control, now the Centers for

Dis-ease Control and Prevention (Bonnie & Guyer, 2002). Substantially incrDis-eased infusions of money into the field attracted new researchers and the volume of injury research expanded dramatically after the publication of the report (Rivara, 2001). Since the 1990s, the injury field has drawn the attention of a continually broadening range of disciplines, encompassing epidemiology, biomechanics, acute care, rehabilitation, psychology, criminology, economics, and other social and behavioural sciences (Bonnie & Guyer, 2002).

During the 1990s, research and program development within the injury field gave greater attention to the study of intentional injuries, reflecting a broader movement within public health embracing the cause of violence prevention (Bonnie, 1999). A 1999 report by the Committee on Injury Prevention and Control (established by the IOM), titled Reducing the Burden of Injury: Advancing

Prevention and Treatment, endorsed the previously stated position for continued

integration of all injury prevention activities, including violence prevention, within a common framework of research and program development (Bonnie & Guyer, 2002).

Reducing the Burden of Injury: Advancing Prevention and Treatment strongly argued

for the displacement of the term “accident” with the term “injury.” Injury re-searchers and practitioners had for many years discouraged the use of “acci-dents” when it refers to injuries or the events that produce them. They believe it reinforces public misconception that injuries are unpredictable and unprevent-able random events or “acts of God.” Moreover, not all accidents result in inju-ries (Christoffel &Gallagher, 1999). In 2001, all British Medical Journal speciality journals, including Injury Prevention, resolved to “ban” inappropriate use of the word “accident” in their pages. The decision, announced in an editorial in the

BMJ, prompted an outpouring of letters to the editor. “When the dust settled,

the result was a draw with equal numbers of letter writers supporting this step toward enlightenment while all others were entirely condemnatory,” editors Pless and Hagel commented in 2005 (Pless & Hagel, 2005, page 182).

In the new century, injuries remain a profoundly important public health problem, and there is growing recognition of the significance of the problem and the need for steps to address it. As with many other public health problems, the pace of prevention may seem slow, but it is steady and its momentum is growing. In fact, even the use of the dreaded “A” word does seem to be in de-cline.

References

AAP (1997). Injury Prevention and Control for Children and Youth. Elk Grove Village: American Academy of Paediatrics.

Academy of Achievement (2006). Ralph Nader: A Profile. Available from:

http://www.achievement.org/autodoc/page/nad0pro-1 (last accessed: 17 June 2006).

Angus DE, Cloutier E, Albert T, et al. (1998). The Economic Burden of Unintentional

Injury in Canada. Canada: Smartrisk.

ASCF (2006). Australian Safe Communities Foundation. Available from:

http://www.iccwa.org.au/Safe%20Communities/ASCF/ASCF_brochure_f inal.pdf (last accessed: 8 January 2006).

Barry PZ (1975). Individual Versus Community Orientation in the Prevention of Injuries. Preventive Medicine, Vol. 4: 47-56.

Berger LR, Mohan D (1996). Injury Control: A Global View. Dehli: Oxford Uni-versity Press.

Bonnie RJ (1999). Reducing the Burden of Injury. Washington DC: National Acad-emy Press.

Bonnie RJ, Guyer B (2002). Injury as a Field of Public Health: Achievements and Controversies. Journal of Law, Medicine & Ethics, Vol. 30: 267-280. Christoffel T, Gallagher SS (1999). Injury Prevention and Public Health.

Gaithers-burg: Aspen Publishers.

De Haven H (1942). Mechanical analysis of survival in falls from heights of fifty to one hundred and fifty feet. War Medicine, Vol. 2: 586-596.

Fincham S (1992). Community health promotion programs. Social Science and

Medicine, Vol. 3: 239-249.

Gibson JJ (1964). The contribution of experimental psychology to the formula-tion of the problem of safety – a brief for basic research. In: Accident

Re-search: Methods and Approaches. Haddon W, Suchman EA, Klein D, editors.

New York: Harper & Row. Pp: 296-303.

Gordon JE (1949). The Epidemiology of Accidents. American Journal of Public

Health, Vol. 39: 504-515.

Haddon W (1963). A Note Concerning Accident Theory and Research with Special Reference to Motor Vehicle Accidents. Annals New York Academy of

Sciences, Vol. 107: 635-646.

Haddon W, Suchman EA, Klein D (1964).Toward a Science of Accident Re-search. In: Accident Research: Methods and Approaches. Haddon W, Suchman EA, Klein D, editors. New York: Harper & Row. Pp: 1-12.

Haddon W (1968). The Changing Approach to the Epidemiology, Prevention, and Amelioration of Trauma: The Transition to Approaches Etiologically rather than Descriptively Based. American Journal of Public Health, Vol. 58 (8): 1431-1438.

Haddon W (1970). On the Escape of Tigers: An Ecological Note. American

Jour-nal of Public Health, Vol. 60 (12): 2229-2234.

Hanson D, Vardon P, Lloyd J (2004). Safe Communities: An Ecological Ap-proach to Safety Promotion. Available from:

http://www.jcu.edu.au/school/sphtm/documents/rimnq/Paper2.pdf (last accessed: 17 December 2004).

Harms-Ringdahl L (1993). Safety Analysis – Principles and Practice in Occupational

Safety. London: Elsevier Applied Science.

Jeffs D, Booth D, Calvert D (1993). Local injury information, community par-ticipation and injury reduction. Australian Journal of Public Health, Vol. 17 (4): 365-372.

Moller J (1992). Community-Based Injury Prevention. In: Community-Based Injury

Prevention. Cowandilla: The National Safety Council of Australia. Pp: 17-23.

Nader R (1991). Unsafe at Any Speed: The Designed-In Dangers of the American

Auto-mobile. Massachusetts: Knightsbridge.

Pearn J, Nixon J, Scott I (2004). An historical perspective. In: The Scientific Basis

of Injury Prevention and Control. McClure R, Stevenson M III, McEvoy SP,

edi-tors. East Hawthorn: IP Communications. Pp: 5-17.

Pless IB, Hagel BE (2005). Injury prevention: a glossary of terms. Journal of

Epi-demiology and Community Health, Vol. 59: 182-185.

Reason J (2000). Human error: models and management. BMJ, Vol. 320: 768-770.

Rivara FP (2001). Introduction: The Scientific Basis for Injury Control.

Epidemi-ologic Reviews, Vol. 25: 20-23.

Robertson LS (1998). Injury Epidemiology: Research and Control Strategies. New York: Oxford University Press.

Runyan CW (2003). Introduction: Back to the Future – Revisiting Haddon’s Conceptualization of Injury Epidemiology and Prevention. Epidemiologic

Re-views, Vol. 25: 60-64.

SCF (2006). Safety Culture: The Safe Communities Foundation. Available from:

http://www.safecommunities.ca/ohsapril.htm (last accessed: 12 January 2006).

SCFNZ (2005). Safe Communities Foundation NZ. Available from:

http://safecommunities.org.nz/ (last accessed: 9 December 2005) SRV (2004). Olyckor i siffror. Karlstad, Sweden: Räddningsverket. [In Swedish] Stapp JP (1957). Human Tolerance to Deceleration, American Journal of Surgery,

Vol. 93: 739.

Stevenson M, Ameratunga S, McClure R (2004). The rationale for prevention. In: The Scientific Basis of Injury Prevention and Control. McClure R, Stevenson M III, McEvoy SP, editors. East Hawthorn: IP Communications. Pp: 34-44.